Safe Care

Transitions for

Suicide Prevention

Utah Zero Suicide Learning Collaborative

2018

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TABLE OF CONTENTS

INTRODUCTION ________________________________________________ Error!

Bookmark not defined.

BEST PRACTICE MENU OF STRATEGIES____________________________ 4-9

CREATING AN OFFICE PROTOCOL FOR TRANSITIONS IN CARE ________ 10-11

SAMPLE OFFICE PROTOCOLS ____________________________________ 12-14

ADDITIONAL RESOURCES ________________________________________ 15

WORKS CITED __________________________________________________ 16

Appendix A- Psychoeducation Examples ______________________________ 17-21

Appendix B- Caring Contact Examples ________________________________ 22-25

Appendix C- Follow Up Phone Call Script Example ______________________ 26-27

Appendix D- The Joint Commission Tips for High-Quality Hand-Offs_________ 28

For technical assistance and support in using this toolkit, please contact Kimberly Myers at

the Utah Division of Substance Abuse and Mental Health, kmyers@utah.gov

or visit zerosuicide.sprc.org.

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Introduction

Transitions in care include discharge from hospital inpatient or emergency department,

referral after suicide risk assessment in a primary care or crisis setting, or any time when a

patient at risk of suicide is between care providers. These gaps in care are times of

heightened risk, especially after discharge from inpatient care. A 2017 systematic review

found that the post-discharge population has a rate of suicide that is 100 times higher than

the general global population, specifically in the first three months after discharge (Chung et.

al, 2017). Suicide rates generally peak in the first week after discharge from psychiatric

inpatient care (Qin & Nordentoft, 2005; Appleby et al., 1999).

Strategies to promote continuity of care are needed to address these periods of heightened

risk, particularly for individuals that are difficult to engage in treatment (e.g. underinsured, low

socio-economic status individuals, and males). Many individuals undergoing care transitions

experience a complete lack of support during high-risk transitions in care or when ongoing

services are interrupted (e.g. an appointment is missed). These gaps in care are

unacceptable for high risk individuals and changes in systems and practices are urgently

needed.

The Larger Whole of Zero Suicide

Continuity of care strategies are an important piece of Zero Suicide, a systems quality

improvement framework that has many components with evidence of effectiveness in

reducing suicide attempts and deaths. The data assures us that when all of the Zero Suicide

strategies are practiced in combination and through a lens of continuous quality improvement,

that suicide deaths and attempt rates in health and behavioral health care systems are

significantly reduced. To learn more, visit zerosuicide.sprc.org, or email Andrea Hood at

ajhood@utah.gov.

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Best Practice Menu of Strategies for Providing Continuity of Care

This section provides promising and evidence-based strategies for improving continuity of

care, increasing engagement in outpatient treatment; and reducing suicidal ideation,

attempts, and deaths. Each strategy is defined and different levels of adoption are presented,

stratified by resources required and effectiveness. The “Good” classification often describes

common current practices or a slight improvement to current practices, where “Better” and

“Best” categories reflect movement towards ideal recommended best practices. The

document begins by describing large systems reform/interagency strategies and gradually

moves toward individual patient level strategies to ensure safe care transitions. The goal is to

have entire systems shift towards best practice, with the most resource-intensive strategies

primarily implemented with patients at highest risk of suicide.

Stepped Care

Stepped care refers to a continuum of treatment intensity based on the needs of the

individual. Rather than relying only on traditional models of outpatient care and emergency

departments only, stepped care offers a broader range of care including intensive outpatient,

mobile crisis supports, crisis stabilization units, peer support, and other creative solutions to

meet the needs of individuals in the least restrictive setting possible.

Good: Providing 24-hour access to crisis resources over the phone/SMS texting, and utilizing

the Emergency Department for acute or imminent suicide risk

Better: All of the above, and providing intensive outpatient options, crisis stabilization units,

walk in crisis centers, and/or mobile crisis.

Best: All of the above, and providing peer support, linked EHRs, and/or an “air traffic control”

center to deploy mobile crisis and monitor availability of inpatient bed availability in real time

(See http://bhltest2.com/ for more information and resources in reforming crisis care).

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MOUs/MOAs

Memorandums of understanding (MOUs) with partner organizations (e.g. local hospital)

outline the role that each entity has for screening, assessment, safety planning, discharge

planning and follow-up to allow multiple agencies to coordinate care. MOUs can assist in

providing clear arrangements for information sharing, including establishing procedures for

access to relevant assessment information and policies around warm hand-offs/rapid

referrals.

Good: Having informal agreements with identified contacts at referral agencies.

Best: MOUs or contracts provide rapid referral for clinical mental health services with a policy

in place around care coordination (including warm hand-offs, rapid referrals, stepped care

options); and includes defined information sharing (e.g. comprehensive evidence based

suicide risk assessment, safety plan, discharge plan). Records and assessment information

are shared directly through a linked electronic health record if possible.

Warm Hand-offs

Warm hand-offs provide an introduction to the new care provider before the care transition, to

build a relationship with the referred provider or organization and decrease no-shows. This

contact could include care coordination dialogue (current provider to referred provider), and

care navigation support (individual to referred provider). The referring provider may arrange

an introduction with the new provider in person, by phone or through telehealth technology.

Alternatively, the referring provider may make a linkage with another staff within the referral

organization, such as a peer provider or continuity of care staff, who is responsible for

maintaining care throughout the transition time for the person at risk.

Good: A policy is in place for peer support, support staff, or crisis worker from the receiving

organization to be introduced to the patient before discharge or care transition over the

phone.

Better: An in person meeting is arranged between the patient and the identified provider (or

peer support, staff, or crisis worker) prior to discharge. *If inpatient, the patient would ideally

begin outpatient treatment prior to discharge, with the referred care provider. Warm hand-offs

of this kind may triple the odds of a patient engaging in outpatient behavioral health care

(Boyer et. al, 2000).

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Appointment Scheduling

Organizations do their best to ensure that individuals have rapid access to initial outpatient

appointments following discharge/referral. Providers supporting care transitions, such as

crisis staff, should have the capacity to schedule follow-up appointments while still engaged

with the individual at risk. Consider use of telebehavioral health when appointments are not

readily available. The sooner the follow up appointment can be scheduled the better, and the

ideal is to maintain consistent contact with the patient during the care transition.

Good: Follow-up appointments are scheduled within 7 days, while the referring provider is still

engaged with the individual at risk. Receiving provider provides reminder phone calls.

Better: Follow-up appointments are scheduled within 24-72 hours while the referring provider

is still engaged with the individual at risk. Patients are engaged in scheduling their

appointment and patient preferences and needs are taken into account. Reminder phone

calls are provided to improve attendance at scheduled appointments, and a procedure is in

place to identify no shows and attempt to contact them or their family members to ensure the

patient is safe/activate crisis response if necessary.

Best: Follow-up appointments are scheduled within 24 hours while the referring provider is

still engaged with the individual at risk (particularly important after discharge from inpatient

care). Reminder phone calls are provided to improve attendance at scheduled appointments,

and a procedure is in place to identify no shows and attempt to contact them or their family

members to ensure the patient is safe/activate crisis response if necessary. Referring

provider follows up with phone call to ask how the appointment went and if another referral is

needed.

Provider Communication

The care transition should be supported through effective communication between the

referring provider and the receiving provider. Providers should send documentation on the

individual at risk prior to the scheduled appointment and follow up with a conversation

between providers to share relevant information. Provider communication including

communication of patient discharge plans prior to the first appointment may triple the odds of

a patient engaging in outpatient behavioral health care (Boyer et. al, 2000).

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Good: Once a Release of Information is in place, send the assessment and discharge

paperwork, and treatment plan if applicable to the receiving provider, prior to or at the first

appointment.

Better: Referring provider does all of the above, and communicates patient history,

social/environmental context, assessment and diagnosis, over phone or email to receiving

provider. Additional ROIs are put in place to facilitate ongoing care coordination with social

supports and care providers.

Best: In person or over the phone treatment team meeting that includes the individual at risk,

the individual’s social support persons, and all applicable providers, case managers, school

team, peer supports, or other services a person might need. Care coordination meetings

recur as needed. Provider communication takes place between systems using MOUs and

shared EHRs, for example when a crisis services provider communicates back to the

outpatient provider, or vice versa.

Care Navigators/Community Health Workers/Case Management

Care navigators have been shown to be especially helpful in providing continuity across

primary care and behavioral health systems and across hospital and outpatient settings. The

care navigator can enhance these system relationships by serving as a liaison, improving

communication across providers and facilitating access to care. The use of motivational

enhancement strategies may increase the effectiveness of care navigation and care

coordination. They also provide support to the patient to increase engagement in care.

Good: Providing care navigation services between treatment systems and settings.

Better: Having identified care navigators specific to behavioral health, and/or specific to

populations such as Veterans, youth, refugee populations, etc.

Peer Specialist Support

Organizations can engage internal or external peer specialists to assist individuals at risk in

navigating behavioral health systems and provide support and encouragement during the

transition period and possibly beyond. One study demonstrated that utilizing peer support

organizations in the discharge process shortened the length of hospitalization, reduced the

use of hospital and ED services over 12 months, and reduced the overall cost of care

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(Forchuk, Martin, Chan, & Jensen, 2005). The intervention was most beneficial for those

individuals describing themselves as “lonely.”

Good: A procedure is in place to consistently refer to external peer support organizations

upon discharge such as NAMI Utah or the local mental health authority.

Better: Employing certified peer support staff to build relationships with patients before

discharge or transition and continue working with patient during the transition in care.

Engagement of Support Network

This strategy includes involving supportive family or friends through education around the

elevated risk period and inclusion in the discharge and transition planning. Persons in the

individual’s support network can also be included in plans to reduce access to lethal means.

Information should be shared regarding crisis services, the patient’s safety plan, community

supports, and outpatient care.

Good: At least one person from the support network is involved in discharge and treatment

planning. This has demonstrated to triple the odds of a patient engaging in outpatient

behavioral health care (Boyer et. al, 2000).

Better: All of the above, and having a Release of Information signed by the individual

receiving care to allow ongoing communication with support person, especially to ensure

access to lethal means is reduced, and to check on a patient who no-shows for an

appointment and isn’t responding to attempts to contact.

Psychoeducation

Providers engage in conversations with an individual to identify expectations regarding

mental health diagnoses, treatment, and prognosis; provide information and clarify

misconceptions, discuss potential barriers to treatment and problem solve. Psychoeducation

should include an understanding of the individual’s cultural beliefs about suicide and mental

health treatment and the role these beliefs may play, using motivational interviewing

techniques.

Good: Provider gives the patient educational materials about their diagnosis, treatment, and

treatment outcomes.

Better: Provider gives the patient educational materials and discusses them with the patient

and the patient’s social supports. This psychoeducation should continue throughout the

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treatment process.

Best: All of the above, and as part of treatment, provider increases access to social supports

and examples of individuals living in recovery including peer support specialists.

Caring Contacts

Caring contacts can be done by staff in any program that has provided acute care (e.g.,

emergency department, crisis, or inpatient programs), by outpatient programs that provide

ongoing care (during high risk periods, when an appointment is missed, or treatment is

discontinued), or by crisis centers that can conduct follow-up under contract with other

services (National Action Alliance for Suicide Prevention: Transforming Health Systems

Initiative Work Group, 2018). These contacts are brief communications expressing care from

a provider and could be delivered in person, by phone, letter or postcard, email, or text.

Caring contacts follow a pre-set schedule and have ranged in studies from 1 to 24 contacts

with most lasting for up to 18 months. A review of the evidence supporting caring contacts

found that various methods of supportive contacts can be effective (Luxton et al., 2013)

Examples of caring contacts can be found on the Resources page of the Zero Suicide

Website

(http://zerosuicide.sprc.org/resources?type_1%5B%5D=tool&field_toolkit_tid%5B%5D=4).

Good: One or more emails, texts, or postcards are sent to the individual during care

transitions.

Better: Phone calls are provided by support staff or peer supports in addition to or in lieu of

the emails, texts, or postcards. Phone calls are considered a higher level of support because

it allows crisis services to be activated if needed.

Best: Structured follow up and monitoring is provided via phone or in person by a nurse or

mental health clinician in addition to emails, texts, or postcards. Phone calls or visits are

used to assess risk, edit safety plan, and increase engagement in outpatient care. A policy is

in place to determine how long caring contacts are given (e.g. until the person is engaged in

care, until suicide risk is reduced, or for several months-years if neither of those conditions

are met). Structured follow up and monitoring may also be used for patients already engaged

in care between outpatient appointments.

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Creating an Office Protocol for Transitions in Care

This section is intended to provide a practical guide for entities who wish to implement

continuity of care strategies. Please review the following considerations to guide your protocol

development and implementation.

1. Review the continuity of care options presented in the companion document (Best

Practices Menu of Strategies for Providing Continuity of Care) and select options that

are feasible for your agency.

2. Establish agreements with outpatient treatment providers to facilitate rapid referrals

(ideally within 24 hours from inpatient settings and 72 hours from outpatient settings)

for high-risk patients; and develop an office protocol to provide follow up contacts with

discharged/referred patients that have identified suicide risk.

3. Considerations for follow up outreach may include staffing patterns and capacity of

provider performing outreach to determine whether simple caring contacts or more

structured follow up and monitoring will be provided. In developing office protocols,

agencies should clearly define the following:

a. Criteria of patients who will receive follow up contacts (discharged from

psychiatric inpatient or ED, medium to high suicide risk identified by screening,

referral to specialty provider for suicide risk, and/or patient at risk of suicide who

no shows/refuses treatment/drops out of treatment)

b. Goals and content of follow up outreach (engage in outpatient care, monitor

risk, provide support)

c. Staff member who will obtain a signed Release of Information to contact patient

social supports and support/treatment team, and template for the ROI.

d. Provider who will provide contact (therapist, nurse, peer support, case manager,

or support staff). *Research indicates that having clinical staff perform this

function is likely to have a greater impact on outcomes

e. Types of contacts provided (call, text, email, and/or letter are most common;

home visits are effective in hard to engage populations)

f. Frequency of follow up contacts (daily or minimum of every three days is

recommended during transition from inpatient psychiatric care)

g. Minimum number of contact outreaches to be made and maximum number of

attempts to be made prior before it is assumed they have dropped out of the

program

Criteria for how long the contacts will be provided could be based on research

or based on individual patient needs.

h. Create a template for Caring Contacts that can be mailed, emailed, or SMS

texted if that will be part of your follow up efforts

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4. Outline who is responsible for each Continuity of Care task in your organizational

policy and train staff on both their role and resources available to patients. Provide

regular suicide prevention training to all staff who will be interacting with patients.

5. Develop/define method for documenting and monitoring each Continuity of Care task.

Consider building follow up procedures into the electronic health record, possibly

including, but not limited to:

a. Patient appointments inside or outside the organization

b. An automated method of flagging no-shows that will result in staff prompts to

take defined action to locate the person, ensure their safety, and reschedule the

appointment or link them to a higher level of care if appropriate.

c. An electronic method for sharing patient health information with the receiving

provider.

6. Use quantitative and qualitative measures to determine the success of Continuity of

Care efforts. Review 30 days in, and then regularly at predetermined intervals to refine

process as needed.

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SAMPLE OFFICE PROTOCOL

For Referring Agency, Prior to Discharge

1. _____________________ will provide brief patient education (including printed

materials) that helps the patient and family understand the patient’s diagnosis, the

concept of recovery, the options for treatment and support, and the purpose and

probable duration of treatment. Identify and address barriers to accessing treatment

(e.g. logistical barriers, financial concerns, or beliefs regarding treatment and

recovery).

2. _____________________ will obtain patient consent through an ROI to share patient

health information with patient’s support team, follow up with patient and social

supports after a missed appointment, and provide follow up outreach to the patient.

Support team may include prescribing medical provider, behavioral healthcare

providers, key social supports, wraparound service providers (i.e. housing,

employment services, peer specialists, vocational rehab, relevant school personnel,

etc). Identify preferred contact methods with patient for follow up care: call, text, email,

or mail, and contact information.

3. _____________________ will define with patient the goals and duration of follow up

contacts (e.g. follow up until re-linked to treatment, follow up until specific stressor is

past, or follow up until suicide risk assessment shows reduced risk).

4. _____________________ will provide the patient with assistance navigating the

options for treatment and recovery supports described in #2 above. (Preferably a peer

or case manager).

5. _____________________ will collaborate with the patient to create/revise their safety

plan and ensure they have a copy. The patient will be asked to write the plan in their

own words and/or repeat it back to ensure they understand.

6. _____________________ will facilitate a phone call with the patient and identified

provider at receiving agency, to promote rapport and adherence to discharge treatment

plan. When this is not possible, arrange an in-person or telephone meeting with a peer

specialist, crisis worker, or other staff from the receiving agency.

7. _____________________ will send patient records to identified provider(s) at receiving

agency in advance of the appointment, and follow up that records were received.

8. _____________________ will contact new provider at receiving agency to review

patient information, emphasizing suicide assessment, prior health and behavioral

health care, and identified barriers to treatment, prior to the first appointment.

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For Referring Agency, Following Discharge

1. _____________________ will contact the patient within 24–48 hours after they have

transitioned to receiving care provider to promote adherence to treatment plan,

engagement in services, and safety. Document all contacts or failed contacts.

2. _____________________ will contact the receiving agency to confirm attendance at

scheduled appointment, address clinical questions or identified barriers, and/or to

review appropriateness of referral where applicable.

3. If patient no-shows to scheduled appointment, _____________________will attempt to

contact patient and applicable supports as identified prior to discharge.

4. _____________________ will follow up with ____ (#) caring contacts over

_______________ (time period) after discharge or referral, using method of contact

preferred by patient (phone, text, email, letter), until they are engaged in care, risk is

reduced, or they decline continued follow up contacts. The content of these contacts

may be drafted to provide an “open door” for care, and provide interpersonal

connectedness and support.

5. _____________________ will review EHR on a _____________________ basis to

determine that the office protocol is being followed, discuss with staff, and revise

process as necessary.

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SAMPLE OFFICE PROTOCOL

For Receiving Agency

1. _____________________ will prioritize appointments to be scheduled as soon as

possible when suicide risk is present, using predetermined process. Best practice

would be scheduling them within 24 hours, particularly when referred from higher

levels of care or when risk is high.

2. _____________________ will contact patient within 24 hours prior to scheduled

appointment for an appointment reminder, to answer questions and address any

barriers to accessing treatment or appointment. (If support staff make reminder calls

they must be trained in suicide prevention and able to consult with provider if concerns

arise.) Ensure documentation of all contacts or failed contacts.

3. _____________________ will flag no-shows in EHR and communicate with provider.

_____________________ will make phone calls to locate the person, ensure their

safety, and reschedule the appointment or link them to a higher level of care if

necessary.

a. If patient cannot be reached, _____________________ will contact referring

agency and request they contact patient social supports.

4. _____________________ will review EHR on a _____________________ basis to

determine that the office protocol is being followed, discuss with staff, and revise

process as necessary.

“It is critically important to design for zero even when it may not be theoretically possible…It’s about purposefully aiming for a higher level of performance.” Thomas Priselac President and CEO of Cedars-Sinai Medical Center

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ADDITIONAL RESOURCES

For information and resources about all components of Zero Suicide:

http://zerosuicide.sprc.org/

For examples of caring contacts:

http://zerosuicide.sprc.org/resources?type_1%5B%5D=tool&field_toolkit_tid%5B%5D=4

For online training “Structured Follow Up and Monitoring”

http://zerosuicide.sprc.org/sites/zerosuicide.sprc.org/files/monitor_suicidal_individuals/course

.htm

For more information about suicide prevention in the Emergency Department Setting:

https://www.sprc.org/edguide

For more information about suicide prevention in the Primary Care setting:

https://www.sprc.org/settings/primary-care

For information and resources after a suicide attempt or loss:

https://afsp.org/find-support/

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WORKS CITED

Boyer, C.A., McAlpine, D.D., Pottick, K.J., and Olfson, M. (2000) Identifying risk factors and

key strategies in linkage to outpatient psychiatric care. American Journal of Psychiatry

157:10, 1592-1598.

Forchuk, C., Martin, M. L., Chan, Y. C. L., & Jensen, E. (2005). Therapeutic relationships:

From psychiatric hospital to community. Journal of Psychiatric and Mental Health Nursing, 12,

556–564.

Luxton, D. D., June, J. D. & Comtois, K. A. (2013). Can post-discharge follow-up contacts

prevent suicide and suicidal behavior: A review of the evidence. Crisis, 34, 32-41.

Mishara, B. L., Houle, J. and Lavoie, B. (2005), Comparison of the Effects of Four Suicide

Prevention Programs for Family and Friends of High-Risk Suicidal Men Who Do Not Seek

Help Themselves. Suicide and Life-Threatening Behavior, 35: 329–342.

doi:10.1521/suli.2005.35.3.329

Motto, J.A., & Bostom, A.G. (2001). A Randomized Controlled Trial of Postcrisis Suicide

Prevention. Psychiatric Services, 52(6): 828-833. Retrieved from

http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.52.6.828

Richardson, J.S., Mark, T.L., & McKeon, R. (2014). The return on investment of

postdischarge follow-up calls for suicidal ideation or deliberate self-harm. Psychiatric

Services, 65, 1012-1019.

Van Heeringen, C., Jannes, S., Buylaert, W., Henderick, H., De Bacquer, D., & Remoortel, J.

(1995). The management of noncompliance with referral to out-patient aftercare among

attempted suicide patients: A controlled intervention studies. Psychological Medicine, 25,

963-970.

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APPENDIX A Psychoeducation Examples: AFSP and SPRC

AFSP After an Attempt Resources (https://afsp.org/find-support/ive-made-attempt/after-an-

attempt/)

Immediately after an attempt

Maybe you have just returned home from the hospital…or you may be trying to make sense of

what led you to consider suicide. The “why” of suicide is complex and answers may not come

easy.

Your journey of healing is one that many have been on and survived. Your life matters.

How did I get here?

You may not understand all of the thoughts and feelings that led you to consider suicide, and

that’s okay.

Many people who feel suicidal are experiencing a mental health concern, which is treatable.

You may also have been experiencing stressful life events, found it difficult to express your

feelings, or felt yourself isolating from others.

While you may still have challenges, many people who survive a suicide attempt begin to see

those challenges in a new light, and realize that there are people available to support them.

You don’t need to have all of the answers to heal from this experience. There is a way

through.

Interacting with family and friends

Sometimes people do not know what to say following a suicide attempt. They may be

frightened, confused, or angry, and say things that are not helpful to your recovery. They may

also avoid discussing it with you.

They may need time to process what has happened. Their journey is not your journey

however, and you are not responsible for how they decide to work through their feelings.

If asked about your attempt, tell people what you are comfortable telling them, or that you

need time. Find a therapist or other mental health professional and/or a support group. Enlist

the help of family and friends with day-to-day responsibilities for a time, if needed.

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Things you can do to support your recovery

You have experienced a significant health event, and just as you would while recovering from

any other health concern, you will need time, reflection, and support from others during your

recovery.

Be kind to yourself. You have just survived a life-threatening health crisis and you deserve to

take the time you need.

Take care of your health. Exercising, eating right, getting enough sleep and spending time

with healthy people can have a huge impact on your health and mood.

Find a mental health professional. A good therapist or doctor can help you put this experience

in proper perspective. They can also help you develop a safety plan and find ways to address

life stressors.

Try a support group. There are different kinds of support groups, including those for

depression and other mental health conditions and for those who have survived a suicide

attempt. A group can help you know you are not alone.

Talk to those you trust. When you’re ready, let them know what happened and that you want

them to help you stay safe.

Join our AFSP community. Whether you visit our website, attend a community presentation,

join a volunteer committee, or attend a walk, you will be connected to people who understand

the complexity of suicide and want to help prevent it.

Safety Plan

Having a safety plan that addresses the following is an essential component of your recovery:

Recognize what puts you at risk.

Find coping strategies that do not rely on the presence of others.

Engage with people and go to places that help take your mind off your problems.

Reach out to family or friends that can help you in a crisis.

Call the National Suicide Prevention Lifeline at 1-800-273-8255

Keep your environment safe.

Information for family and friends

If your loved one has made a suicide attempt, it is important that you seek support and take

steps to care for yourself and them.

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SPRC “Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency

Departments,” pages 9-10, (https://www.sprc.org/edguide).

The Brief Patient Education intervention helps the patient understand his or her condition and

treatment options and may facilitate patient and family adherence to the follow-up plan. As

patients with suicide risk often do not attend follow-up mental health appointments after

discharge, the ED visit may be the best—or only—opportunity to provide these patients and

their family members with important suicide prevention information. Written materials may

complement, but not replace, direct, one-on-one communication between provider and

patient.

Action Steps

» Ask the patient for permission to include his or her family members, close friends, and/or a

certified peer specialist in the intervention. A peer specialist is a person with lived experience

who is trained and certified to provide services to others.

» Discuss the following:

✓ Patient’s current condition

✓ Risk and protective factors

✓ Type of treatment and treatment options

✓ Medications and adherence

✓ Substance use

✓ Home care

✓ Lethal means restriction

✓ Follow-up recommendations

✓ Signs of a worsening condition (e.g., increased frequency of suicidal thoughts,

increased trouble sleeping) and how to respond (e.g., ask friends or family to help keep

you safe, remove access to lethal means).

» Communicate that treatment is effective. For example, tell the patient, “Research shows

that mental health treatment helps people recover from suicidal thoughts or feelings (Brown et

al., 2005; Linehan et al., 2006). If you follow-up with treatment, you will feel better.”

» Explain when a return visit to the ED is warranted.

» Provide verbal and written information identifying the local crisis center or crisis line.

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Assist the patient in making a call to the crisis center before leaving the ED.

» Use teach-back techniques to ensure the patient and his or her family understand the

information provided. For example:

“We talked about important next steps. Can you tell me what you’ll do when you get

home?”

“I want to be sure I explained everything clearly. Can you please explain it back to me

in your own words?”

» Show empathy and respect for patient autonomy and privacy. The goal of the Brief Patient

Education intervention is to instill hope of recovery and to reduce stigma and shame.

» Provide written educational materials, including a list of community resources.

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APPENDIX B Caring Contact Examples

Sourced from http://zerosuicide.sprc.org/resources?type_1%5B%5D=tool&field_toolkit_tid%5B%5D=4

Example 1

Hello __________, We have been thinking about you and want to check in with you regarding how things are going. You left _______________ (provider office or facility) with a plan to _______________ (insert coping strategy) and follow up with ___________________ (provider). Were you able to make it to this appointment? If not feel free to call us at ___________if you would like assistance in rescheduling or if you need anything else. Know that all the people here are ready and willing to lend a hand. Be Well! Example 2 Dear [Client], We are sending this to you as a follow up to your visit on [Date] with [Provider Name]. You are in our thoughts and we care about you. We hope that you are doing well. It is our mission to provide mental health care and promote wellness that is sensitive to your needs. We value you as an essential member of our community. We are always here for you. Feel free to contact us any time [Phone Number]. Blessings to you. Example 3 Dear ________, It has been a little while since you were at ______________, and we hope things are going well for you. If you would like to send us a note we would enjoy hearing from you. Please note the following resources are available to you: (National Suicide Prevention Lifeline and other local resources). Best wishes, Example 4 (Missed Appointments) Hello ___________, I hope you are doing well.

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Over the past few weeks, I have not seen you for our scheduled appointments or been able to reach you. We have called you and your emergency contacts several times to check in, but we have been unable to make contact with you. I hope our not hearing from you means that you are feeling better, but if not, I hope you will remember that we are here if you need us. Please know that I want to continue to be here for you, both to listen and to talk about how our working together is helping or not helping you. Also, I am happy to see if I can offer any community resources that might be helpful to your recovery. I look forward to speaking with you soon, hopefully, for an update on how you are doing, and to offer any support that I can. Please call me at ___________ and if I am not available and you need immediate assistance you can ask for the Clinic Manager. Hope to hear from you soon, Staff Name Title Examples 5 - 8

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Appendix C

Follow Up Phone Call Script Example From University of Utah Healthcare

Follow Up Calls Phone Call Guide/Script:

1. Explain who we are and why we are calling.

a. “Hi, my name is ******* I am a social worker/certified peer specialist with

University Healthcare, I am calling to follow up with you regarding you resent

visit to the ER or recent stay at UNI. We follow up with people after their visit to

see how you are doing, make sure that your needs are being met and offer any

support and resources you might need.”

2. Ask if they are able to talk.

3. General overview of how they are doing, build some rapport.

a. “How have things been going since your discharged from UNI or visit at the ER?”

4. Assess SI/Risk – further assess/offer services as appropriate.

5. Ask if they have been seen in the ER since discharge or the last follow up call.

6. Discussed follow up with discharge plan/outpatient providers.

a. Be specific if the discharge plan states specific appointment, providers, etc.

7. Ask if they have a safety plan/crisis response plan.

a. Are they using it?

b. Has it been helpful/effective?

c. So they need help making any changes to make it more helpful?

d. Do then need help developing one?

8. Ask lethal means questions – counsel further as needed.

a. “We ask everyone this question, if you do not feel comfortable answering that’s ok. Do you own, have access to or have firearms in your home?”

b. If no and it seems further explanation for the question is needed discuss the

importance of safety when someone is at high risk or going through a rough

time.

c. If yes, are they locked up safely? Offer resources for free trigger locks, etc. See

this website to read more about lethal means counseling:

https://www.hsph.harvard.edu/means-matter/recommendations/clinicians/

d. If this topic was not discussed in the initial follow up due to not being able to get

a hold of the individual, and you are able to talk with them on the second, please

discuss it and document as above. We will not have to discuss it each follow up

once it has been addressed.

9. Do they need any other support or resources from us?

10. Educate and make sure they have the number for the CL and WL.

11. Ask if they are ok with future follow up phone calls.

a. Explain that we follow up 4 times in the 90 days after discharge/the ER visit to

provide support, resources, etc.

b. If yes:

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i. Is this the best phone number?

ii. Is there a good or better time or day or day of week?

iii. Is it ok to leave a message?

12. DOCUMENT!!!!

Leaving a Voicemail

1. Make the message very generic; no identifying information.

a. “Hi, this message is for >first name<. My name is ******, I’m a social worker/certified peer specialist with University of Utah Healthcare. I’m calling in regards to your recent clinical visit with us. I just wanted to follow up with you regarding that visit and how you are doing. Please give us a call back here at 801-587-3000/801-587-1055. I look forward to hearing from you. Thank you, goodbye.”

2. DOCUMENT!!!!

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Appendix D The Joint Commission

Tips for High-Quality Hand-Offs